PLEASE PRINT
Name ____________________________________________
Sex F M
Social Security # ______________________________
Date of Birth _________________
Address ________________________________________________
City _______________________________ Zip _________________
Phone Home ____________________________
Work or Cell ____________________________
| Section # | Class Name | $ Amount |
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If paying by Visa, MasterCard or Discover:
Credit Card # ______________________________________
Exp. Date ________________
Name on Card (please print) ______________________________________
Signature ______________________________________________________
IF SIGNING UP FOR TRAFFIC SCHOOL
PLEASE FILL OUT THE INFORMATION BELOW ALSO:
Name of Court (if Stanislaus County give the division, i.e.,
Turlock, Modesto, or Oakdale)
_____________________________________________________________
Driver's License # ____________________________________
Docket or Case # (on your court paperwork) _______________________
